Based on observation, interview, record review, and policy review, the provider failed to ensure the safety and prevention for potential entrapment or injury for 16 residents (5, 18, 19, 47, 67, 72, 83, 97, 99, 103, 108, 112, 126, 137, and 356) who had side rails on their bed and 10 other residents (5, 17, 22, 73, 83, 103, 106, 123, 137, and 453) who had a risk for entrapment related to their mattresses and headboards or footboards. Concerns were identified with: *The safety of the side rails related to their installation, ongoing maintenance, and risk for entrapment. *Documentation for consents for side rail use, alternatives that had been attempted, and education regarding the risk and benefits of side rails. *The safety of mattresses and the potential for entrapment between the headboard and footboard or the gaps within the footboard. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy of F700 was given verbally and in writing on 4/16/25 at 4:21 p.m. to administrator A regarding: *The provider failed to ensure bedrails were securely attached, mattresses were able to be elevated when the side rail(s)/grab bar(s) were moved, and there were gaps greater than five inches between the end of the mattress and the headboard. These identified concerns were related to the bedrail installation, maintenance, and bed zone safety and entrapment assessments. -Observations made throughout the survey and throughout the entire building on 4/16/25 revealed the following: *In residents 18, 47, 67, 97, 108, and 126s' rooms the side rails/grab bars were not securely attached to the bedframe, that created a risk for entrapment and the potential for injury. *In residents 5, 18, 47, 72, 83, 89, 97, 99, and 112s' rooms the side rails/grab bars were not securely attached to the bed frame, and the mattress on those beds were able to be elevated when the side rails/grab bars were moved, that created a risk for entrapment zone and the potential for injury *In residents 5, 22, 73, 83, 89, 106, and 137s' rooms there were gaps greater than five inches between the end of the mattress and the headboard, that created a risk for potential entrapment and injury. *In residents 86, 100, 122, 133, and 148s' rooms there were a bed rail particle board frames in place under the mattresses. There were no bed rails attached. There were two exposed metal installation holes, where the bed rails would attach, that created a risk for potential injury. *Resident 356 was using side rails and did not have a Physical Device and/or Restraint Evaluation and Review assessment completed. *Other residents who had side rails had not been accurately or fully assessed for the use of side rails *The style of bed rail used with the Hill-Rom spring bed frames was not compatible according to the manufacturer's instructions. *Resident 103's bed rail was broken and not secured to the spring bed frame. When weight was applied to the bed rail as if a resident were to use it for mobility and stability, the bed rail buckled backwards potentially creating a fall hazard. The particleboard grab bar frame was broken in one corner creating potential for injury. *The above concerns had the potential to cause serious harm, injury, impairment or death for residents. *A plan for the removal of the immediacy was requested at that time. IMMEDIATE JEOPARDY REMOVAL PLAN On 4/16/25 at 8:39 p.m. the provider submitted the following immediate jeopardy removal plan for review: *A comprehensive assist bar audit has been completed for the 26 of 159 residents. The 26 residents have been corrected on 4/16/2025 as follows: -Assist bars were removed from the beds of residents 5,18, 47, 67,72, 83, 86, 89, 97, 99, 100, 103, 112, 122, 126, 133, and 148. -The bed footboard was removed from resident 453's bed and the family was notified. -Resident 108's bed was replaced as the resident wished to keep the assist bars. -The footplate to hold the mattress in place to prevent gaps of greater than four inches in resident 5, 22, 73, 83, 99, 106, and 137s' rooms were put into place. -A physical device evaluation was completed on 4/7/2025 and updated on 4/16/25 for resident 356. --The residents who had their assist bars removed, resident was educated-family was called and educated for residents with a BIMs score of under 13 or those who could not comprehend education. *Identification of others: -An audit of all grab bars and mattresses in the facility was completed as of 4/16/2025 in order to identify residents at risk for similar deficient practice. Resident was educated if assist bar needed to be removed from their bed-family was called and educated for residents with BIMs score of under 13 or those who could not comprehend education. During the audit, bed rails that were identified as noncompliant were replaced or removed. Care plan and physical device assessment updated as appropriate. *Process/Systemic Changes to Prevent Recurrence: -1. The facility is currently in compliance with the 'Bed Safety and Side Rail Entrapment Resource Packet' which is an internal [corporate] policy. -2. Physical Device Assessments listed in the policy titles 'Restraints Policy' will be completed on April 16th, 2025. -3. During the daily nurse clinical meeting, the team will review and evaluate all new residents to ensure that a comprehensive physical device assessment has been completed in accordance with the Restraint Policy. -4. The Maintenance Supervisor or designee will complete a preventative maintenance task 'Bed Inspection, Testing and Maintenance' [corporate] audit monthly. Maintenance staff were educated task audit on 4/16/25. *Education and Training: -An On-Shift message was sent to all employees' personal phones educating on entrapment and potential entrapment hazards on April 16 at 5:28 p.m. -Education will be provided by a Clinical Learning and Development Specialist or Designee to all staff by April 16, 2025 or prior to their next shift. All staff members not currently on the schedule will receive education prior to their next shift. This training will cover entrapment risk, immediate interventions to address entrapment, and the appropriate personnel to notify if a resident is identified as being at risk. *Monitoring: -Comprehensive audits will be conducted by Quality RN or Designee on resident assist bars weekly x4 [times four] weeks, then biweekly x2 [times two] for two months. Findings will be presented to the Quality Assurance Performance Improvement Committee for review. -Audits will be conducted by Maintenance Supervisor or designee on mattress gaps to ensure compliance weekly. The schedule includes x4 for Four weeks, then bi-weekly x2 for two months. Findings will be presented at the QAPI for review. *Completion Date: -Please consider this IJ removal plan as the facility action to address the immediate concerns of noncompliance. This plan will be implemented and completed on April 16, 2025. The IJ removal plan was accepted on 4/16/25 at 10:18 p.m. The immediate jeopardy was removed on 4/16/25 at 11:15 p.m. after the survey team verified on site on 4/17/25 at 8:45 a.m. that the provider had implemented their removal plan through observation, document review, and staff interviews. After the removal of the immediate jeopardy, the scope and severity of the non-compliance remained an E. Current census was 159 residents. 2. Observation on 4/14/25 at 3:17 p.m. of resident 103's room revealed she had a white metal grab bar on the left side of her bed. Observation on 4/16/25 at 9:57 a.m. of resident 103's grab bars on her bed: *When the left grab bar was pulled away from the bed, it lifted the mattress and separated from the mattress approximately 45 degrees. *Under the mattress the grab bar was attached to a piece of particleboard with a corner broken off. *There were four securement locations, two near the frame of the bed and two over the bed springs. *Neither the grab bars nor the particleboard was secured to the bed frame or the bed springs. Interview on 4/16/25 at 10:11 a.m. with registered nurse (RN) T regarding resident 103 revealed: *She did not use her grab bar. *She was super stiff and difficult to roll in bed and required staff assistance with bed mobility. Review of resident 103's 2/23/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The assessment had a comment that indicated Resident is able to use grab bar appropriately. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 3. Observation on 4/14/25 at 3:33 p.m. of resident 99's room revealed there were white metal grab bars on both sides of her bed. Observation and interview on 4/16/25 at 10:26 a.m. with resident 99 in her room revealed: *The grab bars on both sides of the bed lifted the mattress when pulled on. *Resident 99 stated she used the grab bars for repositioning herself when in bed. Review of resident 99's 3/3/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 4. Observation on 4/14/25 at 3:37 p.m. of resident 89's room revealed she had white metal grab bars on both sides of her bed. Observation on 4/16/25 at 10:20 a.m. of resident 89's bed revealed: *The right grab bar moved freely when pulled on. -It was not secured to the springs of the bed. *The left grab bar was loose when it was pulled on. Review of resident 89's 2/27/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 5. Observation on 4/14/25 at 3:42 p.m. of resident 112's room revealed she had a white metal grab bars on the right side of her bed. Observation on 4/16/25 at 11:00 a.m. of resident 112's grab bar revealed it was loose and lifted the mattress when it was pulled on. Review of resident 112's 2/11/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 6. Observation and interview on 4/16/25 at 9:58 a.m. with resident 19 in her room revealed: *She had a white metal grab bar on the left side of her bed. *The grab bar was loose and pulled the mattress up from the bed when pulled on. *Resident 19 stated that the mattress pulls up even when she is sitting on the edge of the bed and pulls on the grab bar. Review of resident 19's 1/21/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. 7. Observation and interview on 4/16/25 at 10:06 a.m. with resident 47 in her room revealed: *She had a white metal grab bar on the left side of her bed. *There was movement of the grab bar from side to side and up and down when testing it. *Resident 47 was unsure if she used her grab bar in bed or for transfers. Review of resident 47's 3/20/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 8. Observation and interview on 4/16/25 at 10:09 a.m. with resident 97 in her room revealed: *She had bilateral white metal grab bars on her bed. *When the grab bars were pulled in the mattress was lifted from the bed frame. *Resident 97 stated she used her grab bars while she was in bed, and she felt they were loose when she pulled on them. Review of resident 97's 3/4/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Alternatives that have been attempted did not have any documented alternatives. *Documented education related to the grab bars was given to staff. 9. Observation on 4/16/25 at 10:15 a.m. of resident 126's bed revealed: *She had a white metal grab bar on the left side of her bed. *The grab bar was not secured to the bed frame. Review of resident 126's 1/28/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 10. Observation and interview on 4/16/25 at 10:18 a.m. with resident 18 in his room revealed: *He had a white metal grab bar on the left side of his bed. *The grab bar lifted the mattress when it was pulled on. *Resident 18 stated he used the grab bar for repositioning while he was in bed. Review of resident 18's 3/12/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 11. Observation and interview on 4/16/25 at 10:22 a.m. with resident 108 in his room revealed: *He is lying in bed, leaning with most of his body weight on his left grab bar. *He stated he used the grab bar for repositioning in bed and he had noticed that it did get loose at times. Review of resident 108's 4/10/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 12. Observation on 4/16/25 at 10:53 a.m. of resident 67's bed revealed: *He had a white metal grab bar on the right side of his bed. *The grab bar moved slightly when shaken. *The grab bar lifted the mattress when it was pulled on. Review of resident 67's 3/3/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Alternatives that have been attempted did not have any documented alternatives. *The education documented was given to staff. 13. Observation on 4/16/25 at 10:56 a.m. of resident 5's bed revealed: *He had white metal side rails on both sides of his bed. *The right grab bar was loose when it was pulled on. Review of resident 5's 3/17/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 14. Observation and interview on 4/16/25 at 11:10 a.m. with resident 137 in her room revealed: *She had a white metal grab bar on the left side of her bed. *The grab bar was able to be moved in all directions when pulled on. *Resident 137 stated she used her grab bar to get out of bed. *She was aware her grab bar was loose and indicated she would have tightened it if she had a screwdriver. Review of resident 137's 4/7/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 15. Observation on 4/16/25 at 11:17 a.m. of resident 83's bed revealed: *She had a white metal grab bar on the left side of her bed. *The grab bar was loose when it was pulled on. Review of resident 83's 3/17/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 16. Observation and interview on 4/16/25 at 11:20 a.m. with resident 72 in her room revealed: *She had a white metal grab bar on the right side of her bed. *The grab bar lifted the mattress when it was pulled on. *Resident 72 stated she knew the grab bar was loose but had not thought to ask for someone to tighten it. Review of resident 72's 3/22/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 17. Observation and interview on 4/16/25 at 11:28 a.m. with resident 356 in her room revealed: *Her bed had bilateral tall, white, metal bed rails. *She was currently in bed and was not feeling well. *She used the bed rails to reposition herself when she wanted to sit on the edge of the bed. *She used the right side more than the left. *A wooden platform was visible under the mattress and it appeared to be how the bed rail was attached to the bed. -We were unable to view the attachment as the resident was in bed. Observation and interview on 4/17/25 at 8:22 a.m. with resident 356 in her room revealed: *She indicated she used the right bed rail more than the left. *The right bed rail was loose and moved a couple of inches towards the top of the bed and a couple of inches towards the bottom of the bed. -It was attached to a wooden platform that was attached to the bed. *The left bed rail was significantly loose and could be lifted several inches off the bed. -It appeared to be anchored in only one of three available places. Review of resident 356's 4/7/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. Observation on 4/17/25 at 8:33 a.m. with administrator A of resident 356's bed rails revealed. *Administrator A confirmed that the right bed rail was loose and that the left bed rail could be lifted off the bed. *Administrator A stated that the bed rails would be repaired immediately and confirmed that resident 356 would not be allowed to use the bed until it was fixed to ensure her safety. 18. Observations, interviews, and record reviews during the survey identified residents (5, 17, 22, 73, 83, 103, 106, 123, 137, and 453) had concerns with potential entrapment areas on their beds related to the mattresses and the headboard or footboards. Refer to F689, finding 2. 19. Interview on 4/16/25 at 10:43 a.m. with certified nursing assistant (CNA) PP regarding grab bars and side rails on residents' beds revealed: *She had not seen or heard about any issues related to grab bars. *She did not feel resident 103's significant movement of her grab bar was an issue because a resident could have used it to pull themselves up in bed. 20. Interview on 4/16/25 at 11:55 p.m. with administrator B revealed: *Monitoring of the beds was completed monthly with a check mark task by the maintenance staff. *Not all the monitoring was documented in the TELS computerized system. *He was trying to locate more documentation of the beds having been monitored. 21. Interview on 4/16/25 at 12:06 p.m. with administrator A revealed: *A facility-wide assessment of the beds was completed on 2/6/25 and all repairs were completed by maintenance on 2/10/25. *The checklists in the computerized system were not specific to each bed. 22. Interview on 4/16/25 at 12:38 p.m. with administrator B revealed: *Most resident beds that were not in the rehab wing of the building were Hill-Rom beds. *Some of the Hill-Rom beds had pre-installed side rails while others had not. *The Hill-Rom beds that did not have pre-installed grab bars had to have the side rails/grab bars ordered separately by the facility. *Some of the grab bars ordered came from a contracted vendor. *Administrator B did not know if the grab bars ordered from the contracted vendor were manufacturer approved and safe for use for those beds. 23. Interview on 4/16/25 at 3:03 p.m. with registered nurse (RN)/Minimum Data Set (MDS) nurses D and E revealed: *The process for the application of a side rail and grab bars for resident's beds included: -On admission the entrapment evaluation was to be completed, the family would sign a consent and a physician's order for the grab bars would be obtained. -If staff or the resident felt the resident would benefit from a grab bar, the nurse manager would be notified. -If the resident was receiving therapy services, the therapists would be consulted regarding the benefit of the resident getting a grab bar on their bed. -If it was determined the grab bar would be beneficial for the resident, a maintenance work request was to be entered into the electronic maintenance management system (TELS), and the maintenance staff would install the grab bars on the resident's bed. *An entrapment evaluation was to be completed on admission. *The Physical Device and/or Restraint Evaluation and Review was to be completed quarterly, annually, and with a significant change by the MDS nurse. *When the MDS nurse completed the resident's Physical Device and/or Restraint Evaluation and Review assessment they would interview a staff nurse to determine if the resident was using the grab bars. *When asked about education provided as indicated on the Physical Device and/or Restraint Evaluation Review they stated staff were provided education regarding the use of the grab bars or the resident was educated, if the resident was able to understand the education. *If a staff member noticed a loose grab bar a maintenance work order should have been entered for that to be repaired. *Maintenance was responsible for the installation, maintenance, and removal of the grab bars/side rails to ensure resident's safety. 24. Interview on 4/16/25 at 3:41 p.m. with DON R revealed: *The entrapment assessment was completed on the resident's Physical Device and/or Restraint Evaluation and Review. *The MDS nurse would have indicated in the comment box of the Physical Device and/or Restraint Evaluation and Review if they felt the grab bar was an entrapment risk. *There was no formal process for assessing entrapment risks. 25. Interview on 4/16/25 at 4:05 p.m. with administrator B and DON R revealed: *There was no formal process to assess entrapment risk. *Measurements of bed zones was not a portion of the assessment process when grab bars were installed. *Therapy had not assessed all residents' beds or the residents' ability for use related to grab bars to ensure their safety. 26. Review of the provider's resident admission packet revealed: *There was a prefilled consent form for Grab bars on bed. *The consent indicated that prior to the instillation of grab bars the facility must have attempted to use alternatives. *If the alternative interventions attempted were not effective the resident would be assessed for the use of grab bars. -The determination includes a review of risk, including entrapment. The location must ensure the bed is appropriate for the resident and that bed rails [grab bars] are properly installed and maintained. 27. Interview on 4/23/25 at 3:19 p.m. with Social Service Supervisor J regarding resident admissions revealed: *The social services staff completed the admission paperwork with the family or the resident upon the resident's admission. *The consent for the grab bar was in the admission paperwork and was to be presented to all families as an option available to help residents reposition themselves in bed. *The social service staff were to explain to the families the risk of entrapment as well as the other risks identified on the consent form. *The consent form would be readdressed if there was a change in the resident's bed or if there was a request from staff, family, or the resident for a grab bar and there was no consent already on file. *The consent having been completed on admission did not allow for alternative interventions to be attempted prior to determine if there was a need for the grab bar. 28. Interview on 4/23/25 at 4:17 p.m. with DON R revealed: *She agreed with the grab bar consent being completed on admission, there was a potential that no alternatives would have been attempted prior to the application of the grab bar on the resident's bed. *She indicated that often the alternatives would be initiated simultaneously with the application of the grab bar. 29. Review of the January 2010 USER MANUAL for the Resident LTC [long term care] Bed from Hill-Rom revealed: *Use only Hill-Rom parts and accessories. *Do not make modifications to the bed without authorization from Hill-Rom. *Evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death. Review of the July 2018 The Transfer Handle For Spring Style Hospital Beds manufacturer's information revealed: *The Transfer Handle [grab bar] is designed to accommodate a range of different manufacturers. If the device does not easily attach to the bed per the instructions or interferes with the sub-frame, or the mattress does not firmly make contact with the Transfer Handle-DO NOT USE. *These guidelines were developed by the FDA [Food and Drug Administration] for Bed Rails to help prevent entrapment. It is important information to be aware of. 30. Review of the provider's 2/2/24 Bed Safety and Side Rail Entrapment Resource Packet revealed: *A resident's bed should be a place of comfort and relaxation, a safe place. When the bed system does not fit correctly and the resident becomes trapped or injured, the resident's bed is no longer a safe place. *Grab bars or assist bars provide a sturdy and secure handhold to assist residents in repositioning and getting in and out of bed. *Conditions such as agitation, delirium, pain, confusion, incontinence, or uncontrolled body movements can cause the resident to be more active in bed or attempt to get out of bed. The proper sizing of the mattress, the fit and integrity of the bed rail or other design elements such as wide spaces between the bars in the rail can also increase the risk for resident entrapment, injury and in some instances death. *The purpose of the Bed Safety-Including Bed Rails/Side Rails/Assist Bars P&P [policy and procedure] is to: promote bed safety with the appropriate use of bed rails when used for medical necessity to reduce the risk of entrapment as well as the least restrictive alternative to side rails. *It is important to remember that not all rails and mattresses fit all bed frames. *Inspect the bed system for: -Proper installation of side rails or assistive devices such as grab bars. -Rails or assistive devices designed for the bed frame manufacturer. -Rails or assistive devices that meet the design elements of bed safety standards to avoid entrapment injuries or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure cares and services were provided to meet the needs for one of one sampled resident (2) with cognitive impairment, who was dependent on staff for all cares, used a call light at times to alert staff of needs, and had a history of falls. Findings include: 1. Review of the SD DOH FRI submitted on 5/20/24 revealed: -*On 5/18/24 at 12:30 p.m. resident 2 was found in her room by a nurse. -She was lying on her back, on the floor next to her bed. -she was naked and covered in feces. -The resident was assessed and no apparent injury was found. -Resident was able to perform range of motion (ROM) per her baseline without per baseline right side was flaccid (a type of paralysis) from a history of a stroke. -She was assisted off the floor with a hoyer lift, cleaned and put back in her bed. 2. Observation and interview on 5/29/34 at 10:23 a.m. with resident 2 and CNA N revealed: *Resident 2 was well-groomed and seated next to the nurse's station. *CNA N stated resident 2 could verbalize yes or no when asked questions and would display facial expressions. 3. Observation on 5/29/24 at 10:27 a.m. of resident 2 during an occupation therapy session with Occupational therapist (OT) U revealed: *OT U placed electrode pads that were connected to a device that stimulated muscle contractions on her right bicep and the palm of her right hand. *Resident 2 performed arm lifts with her right arm, then then performed right-hand clenching motions. *Resident grimaced and denied pain and continued doing her exercises. * No other therapy activities observed were completed with resident 2 at that time. 4. Observation and interview on 5/29/24 at 11:38 a.m. with resident 2 while in her room revealed: *She communicated by whispering and nodding or shaking her head. *She indicated she had fallen at home but had not fallen at the facility. 5. Interview with CNA N on 5/29/24 at 1:43 p.m. regarding resident 2 revealed. *She had fallen more than once since she had been admitted , but had no significant injuries from those falls. *Resident 2's memory is was not consistent. *She would have crawled out of bed if not watched, *CNA N was not aware of resident 2 having had any fall alarms, or anything being discussed with her family about that. 6. Interview with the licensed practical nurse (LPN) R on 5/29/24 at 1:47 p.m. revealed: *Resident 2 had fallen multiple times since she had been admitted . *The day shift was staffed with two nurses and two CNAs. *She has not worked short-staffed on her shifts. *She had placed resident 2 in her recliner per her request. *A couple of minutes later she stood and fell. *She had no injuries from that fall. 7. Interview on 5/29/24 at 2:00 p.m. with LPN O revealed: *Resident 2 room was located across from the nurse's station. -Resident 2 would have wanted to sleep all day and would have refused to get up at times. -She had a high fall risk. -She had fallen two days ago without an injury. *She would stand up on her own at times. *LPN O had been working there five days when resident 2 fell on 5/18/24. -She had been shown the call light system during her orientation but was not familiar with it and was not sure about fall alarms. *She had not heard the call light system and stated it had not been making a sound. *She was aware resident 2's call light had been on from 11:41 a.m. until 1:05 p.m. the night she fell. *When she went into resident 2's room she found her on the floor. *Resident 2 had been moved to room closer to the nurse's station for increased monitoring. 8. Observation and interview on 5/30/24 at 7:59 a.m. with the director of nursing (DON) D while reviewing the recorded camera video from 5/18/24 revealed: *There was a long call light for resident 2's room from 11:40 to 1:05 p.m. *The video showed the hall from the nurse's station to the end of the hall where resident 2's was located on the right side of the hall. *There were multiple people who had moved up and down the hall whom she identified as visitors. *CNA K was seated near the nurses station, was on her cell phone, and had not answered the call light. *She would have expected CNA K to have made rounds during that time and to have answered call lights. *She said the nurses appeared to have been busy with other duties as they moved about the hall. *The video showed on at least two occasions, staff members had been together in that hall and had not responded to the call light. *She explained when a resident activated a call light the room number would be displayed on a digital board in the hall and at the nurses's station and it would alert to the staff walkie-talkies. *It would have alerted a nurse manager if the call light was not responded to within 15 minutes, then administration if still not responded to after 20 minutes. *It had a digital voice that would announce over the intercom and would repeat, Bedroom nurse call [room number] or Bathroom nurse call [room number]. *The walkie-talkies could be turned off and the volume could be turned down. *The nurse manager was attending to another resident at that time. *She was not sure why resident 2's call light was not answered timely. *She agreed the needs for resident 2 should have been anticipated due to her admitting diagnoses of an aneurysm affecting her right side, impaired cognition and communication, and Clostridium difficile (C-diff, a condition that can cause frequent diarrhea, colon inflammation, and colon damage). *She agreed that resident 2 was incontinent of her bowels during two of her falls. *She agreed that the resident 2's needs related to C-diff had not been anticipated on more than one occasion. *She stated LPN O had been oriented to the call light system. *She stated the nurse on shift LPN O, would have been responsible for CNA K's care she provided to the residents. 9. Observation and interview on 6/3/24 at 8:34 a.m. with resident 2 and LPN O and LPN R revealed: *LPN O had assisted resident 2 from her room and seated her near the nurse's station. *Resident 2 had a laceration to the right side of her head that was actively bleeding and had a raised area on the back of the left side of her head. *Resident 2 indicated she fell after trying to get herself up. *LPN O stated, she was standing at the med cart outside of resident 2's room and heard her fall but did not see her fall. *LPN O then took resident 2 into her room to clean her wound. *LPN R stated she was completing paperwork for resident 2 to transfer to the emergency room for further treatment. 10. Interview on 6/4/24 at 7:20 a.m. with agency RN P revealed: *Resident 2 had fallen on 6/2/24 while she had been working. *No injuries were noted. *She stated she had placed her on 15-minute checks, but these are not documented anywhere as being done. *The 15-minute checks were not being done before resident 2's fall on 6/2/24. *She stated resident 2 should have one-to-one care. *Nurses were to initiate interventions after a resident had a fall. 11. Interview and observation on 6/4/24 at 7:50 a.m. with LPN O and resident 2 revealed: *Resident 2 opened her closed room door independently while in her wheelchair. *She could not open her door while in the room until LPN O showed her the automatic door open button on the wall and then resident 2 opened the door by pushing the button. 12. Interview on 6/4/24 at 7:56 a.m. with clinical care leader registered nurse RN G revealed: *Resident 2's care plan for falls consisted of toileting every 2 hours. *Resident interventions could be seen in a resident chart in the risk management area. *CNAs were to review the interventions in the residents' care plans. *She stated resident 2 could have a mat on the floor but she would be afraid she would trip over it when she tried to get up independently. *She agreed she was moved to room closer to the nurse's station for increased monitoring but it was not on her care plan. *She stated activities were care planned to keep her busy to help with not transferring herself, she did not find this in her care plan while using her computer during the interview. *She was to be seated at the nurse's station for one-to-one monitoring, and this was not on her care plan. *She was aware of the long call light response wait time that occurred on 5/18/24. *She does not do call light audits unless a situation requires audits. *If the nurse manager on the weekend was too busy to assist with a long call light she could have called for assistance. *No fall alarms of any kind are allowed there. *Agency staff do not have access to their policies. 13. Interview on 6/4/24 at 8:56 a.m. with DON D revealed: *Professional standards are their facility policies. *A Brief Interview for Mental Status (BIMS) was the only cognition tool used at the facility unless there was a drastic change in a resident's score. 14. Record review of resident 2's Minimum Data Set (MDS) dated [DATE] revealed: *Her Brief Interview for Mental Status (BIMS) score was 3. *A BIMS score of 00-07 indicated severe cognitive impairment. 15. Record review of Resident 2's incident reports revealed: *On 5/18/24 she was found in her room on the floor naked next to her bed with feces all over her, without injury. This was an unwitnessed fall. *On 5/21/24 she was found kneeling by her bed with her upper torso and arms lying in bed, without injury. This was an unwitnessed fall. *On 5/27/24 she fell by a nurse at the nurses station across from her room, without injury. This was a witnessed fall. *On 6/2/24 She was found on the floor, without injury. This was an unwitnessed fall. 16. Record review of Resident 2's current care plan revealed interventions that included staff were to:: *Ensure/provide a safe environment: pressure call bell available at all times. Initiated and revision date 5/17/24. *Monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance, and lower extremity joint function. *Provided occupational (OT)/speech therapy (ST) cue cards into the resident's room due to impaired speech related to a history of stroke. This was dated 5/20/24, there was no revision date. *There were no other fall interventions indicated in her care plan. 17. Record review of resident 2's electronic medical records (EMR) revealed diagnoses including cerebral infarction (stoke)affecting right dominant side, cerebral aneurysm (ballooning of a blood vessel in the brain), Parkinson's disease without dyskinesia without mention of fluctuations, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and transient cerebral ischemic attack (blocked blood flow that may cause stroke-like symptoms). 18. Record review of resident 2's nurse progress notes revealed: *On 5/17/24 the nursing interventions provided/required by nursing to address the resident's medical condition included, medication administration, encouraged and assisted with ADLs, safe transfers, contact precautions applied for cares, antibiotic administration for Clostridium difficile treatment (C-diff). How effective are the interventions/what progress is the resident making, noted as effective. *On 5/18/24 the LPN O went into the resident's room and found the resident on the floor naked covered in feces lying on her back. The resident was on the floor next to her bed. Resident was assessed for injuries, and no apparent injury was found. Resident able to perform Range of motion without per baseline as her right side remains noted flaccid from history of stroke. Resident assisted off the floor via hoyer lift and cleaned and put back in her bed. Facility protocol being followed. *On 5/19/24 Nursing interventions noted, medication administration, encouraged and assisted with ADLs safe transfers, contact precautions applied for cares, antibiotic administration for C-diff treatment. Effectiveness noted, effective. *On 5/22/24 nursing interventions involved, assist with all cares, able to feed self after set up, assisted as needed, therapy as needed. Effective of interventions noted, monitor safety and anticipate needs. *On 5/20/24 nursing interventions included, medication administration, encouraged and assisted with ADLs, safe transfers, contact precautions applied for cares, antibiotic administration for -diff treatment. Effectiveness noted, effective. *On 5/21/24 note involved, resident was noted kneeling by bed and recliner, upper body and arms on bed, knees on floor. Resident had diarrhea noted on linen, resident was checked and was dry 1 hour prior and staff was doing 15 minute visual checks due to risk of falls. She was seen 5-10 minutes prior to fall and was sleeping. She was alert and assisted back to bed after assessment completed with no injuries noted, range of motion with in normal limits (WNL), vitals signs WNL, neurological exam (neuros) WNL. Resident resting in bed, calm at this time. *On 5/22/24 the nursing interventions involved, assist with all cares, assisted as needed, therapy as needed. Effectiveness noted, monitor safety and anticipate needs. *On 5/24/24 nursing interventions involved, will monitor medications, pain, skin integrity, vital signs and mobility. Effectiveness noted, has been progressed to sit to stand. *On 5/25/24 the nursing interventions involved, medications administration, encouraged and assisted with ADLs, safer transfers, contact precautions applied for cares, antibiotic administration for C-diff treatment. Effectiveness noted, cares need to be anticipated. *On 5/25/24 nursing interventions involved, encouraged and assisted with ADLs, safe transfers, contact precautions applied for cares, antibiotic administration for C-diff treatment. Effectiveness noted, Cares need to be anticipated. *On 5/26/24 nursing interventions involved, medication administration, encouraged and assisted with ADLs, safe transfers, contact precautions applied for cares. Effectiveness noted, cares need to be anticipated. *On 5/27/24 nursing interventions involved, medication administration, encouraged and assisted with ADLs, safe transfers. Effectiveness noted, resident continues to be a high fall risk with frequent checks required. *On 5/28/24 nursing interventions involved, assist with all cares, able to feed self after set up, assisted as needed, therapy as needed. Effectiveness noted, continue to assist as needed, more responsive. *On 6/1/24 the nursing interventions involved, assist with all dressing, hygiene, transfers, bed mobility, locomotion, and toileting. More restless this evening after supper, attempting to verbalize more, Continues poor safety awareness, able to feed self after set up, appetite good, therapy as able. Effectiveness noted, continue to anticipate needs. *On 6/2/24 the nursing interventions involved, assist with dressing, hygiene, transfers, bed mobility, locomotion and toileting. More restless this eve after supper. Attempting to verbalize more. Continues poor safety awareness. Able to feed self after set up. Appetite good. Neuros WNL after unwitnessed fall. Therapy as able. *On 6/3/24 The incident progress note read, After resident was done eating breakfast, resident was put in her room to watch television, while the resident was watching television she attempted to stand up and fell on the floor and hit her head which resulted in a knot to the back of her head and a laceration to the right side of her head that didn't stop bleeding even with pressure. *On 6/3/24 the nurse progress note read, resident returned from emergency room visit following fall this a.m. During her hospitalization the resident received 6 staples to the laceration noted on the right side of her head. 19. Review of the provider's 11/1/23 Rehab/Skilled and Long Term Care Therapy Rehab policy revealed: *Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. *The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and the facility responsibility for providing these services. 20. Review of the provider's 8/1/23 call light policy revealed staff were to:: *Ensure the resident always had a method of calling for assistance. *Promptly answer the residents' call lights. A. Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview and policy review the provider failed to ensure of one of one sampled resident (3) had been accurately accounted for when a door alarm had been activated. Findings include: Notice: Notice of immediate jeopardy was given verbally and in writing on 5/30/24 at 10:41 a.m. to administrator H and director of nursing (DON) D of the immediate jeopardy related to resident elopement and quality of care at F684. On 5/30/24: * At 10:41 a.m. administrator H and DON D were notified of a request for a removal plan. On 5/31/24: *At 8:35 a.m. the removal was received. *At 8:45 a.m. the removal was accepted. On 6/3/24: *At 8:30 a.m. while on-site the survey team verified the immediacy was removed. Plan: 1.On Monday 30, 2024 at 2:52 p.m. on shift message was sent to all employees that summarized the education summary of elopement. This serves as the immediate education for all employees. If staff are not able to complete education on 5/30. They will be required to complete the make-up prior to their next shift. RN S was educated on 5/28 on the process for call DON/Administrator immediately when resident safety is at risk-including elopements. The nurse was also educated on the next step of the policy to initiate a head count of all residents when a door alarm is sounded with not explanation. 2.Certified nursing assistant (CNA) T, on the top half of 200 on 5/26 from 10 p.m. - 6 a.m. was noted to have missed a toileting round of resident 3 at 4:00 a.m. This would have decreased the time of the residents' elopement. The CNA T received a final corrective action on 5/28/ for lack of rounding during this shift. This standard will be upheld for any employees that are found to have failed to complete their rounding as ordered/recommended. 3.All staff were educated on 5/30 on the importance of rounding on all resident's multiple time a shift. Residents with high fall and elopement to chart in the hallways so residents can be in eye site. 4. All staff were educated on utilizing our call system as all exit doors are on the call system to notify all staff if an exit door is alarm on the scrolling screen and the radios. 5. Monday May 27th-when elopement occurred, assessment of resident was completed, and vital signs taken. 6. Tuesday May 28th an elopement drill was completed with day shift around lunch time. Education was provided to staff involved with elopement. 7. Wednesday May 29th around 5 p.m., an potential elopement alert was initiated due to a phone call from someone in the community stating in a resident was outdoors near [NAME] Road. Staff responded to code and facility did head count and everyone was accounted for. 8. Thursday May 30th, hallway and department education is being completed with all staff regarding elopement processes and policy review. Elopement policy/procedure was reviewed, explained what an elopement is, who is considered an elopement risk, steps to take when a potential elopement occurs, who to notify if a resident does elope and how to respond to door alarms and completing head counts if no residents were found when alarm was responded to. 9.Resident 3's physician was out to facility and updated again on recent elopement events. Resident 3's physician ordered lab work-up on him as this an increase in his normal behaviors. He also would like and update on Monday on how he is doing. 10. Elopement Drills will be completed weekly x4. These will be completed on shifts, different days of the week and different locations within the building. Then every other week x 4 weeks. On 5/31/24 8:35 a.m. the removal plan was received. On 5/31/24 at 8:45 a.m. the removal plan was accepted. On 6/3/24 at 8:30 a.m. while on-site the survey team verified immediacy was removed. Once the immediacy had been removed the scope and severity was a G. 1. Review of the SD DOH FRI revealed: *On 5/27/24 at 5:50 a.m. the report had been submitted that indicated resident 3 had eloped (left without staff knowledge) from the facility. *The resident had been located by staff and brought back to the facility. -His vitals were as follows: Temperature 98.0 Fahrenheit, Pulse rate 109 beats per minute, respiratory rate 10 breaths per minute, blood pressure 131/71, and oxygen saturation (oxygen level in the blood stream) of 97%. 2. Review of resident 3 electronic medical record (EMR) revealed he: *Had been admitted on [DATE]. *Had diagnosis of: dementia with agitation. -BIMS (brief interview mental assessment) completed on 5/13/24 with a score of 4 which indicated severe cognitive impairment. *Had been assessed and determined to have a risk for elopement on : -On 2/7/24. -On 2/8/24. -On 5/27/24. *Had an order for the placement of a wander guard (door activating bracelet) on 2/7/24 and to ensure the wander guard was in place twice a day. *Resident 3's care plan was revised on 5/14/24 for staff to have checked the functioning of the wander guard monthly. 3. Interview on 5/29/24 at 10:10 a.m. with resident 3's wife revealed: *She had not been notified of resident 3's elopement when it had occurred, but had not been updated on the provider's investigation. *He had eloped from another facility before. *Resident 3 had a wander guard on his wheelchair since he was admitted on [DATE]. 4. Interview on 5/29/24 at 2:25 p.m. with registered nurse (RN) E regarding resident 3's wander guard placement and function revealed: *She had only checked the placement of the wander guard. *RN E had known that checking the functionality of the wander was to have been performed monthly. -There had not been any documentation of the functionality of the wander guard. 5. Interview on 5/30/24 at 8:50 a.m. with DON D regarding a progress note and investigation timeline of resident 3's elopement revealed: *DON D stated certified nursing assistant (CNA) T had reported that resident 3 had not been assisted with toileting during the 5/27/24 4:00 a.m. rounds. -It was then when the resident 3 had been identified as missing. *Resident 3 had been found and escorted back into the building on 5/27/24 at 5:39 a.m. *RN S had checked the doors when the alarm sounded at 5/27/24 at 3:25 a.m. and had not identified resident 3 as missing. *She agreed that a progress note had not been created to account for resident 3's elopement on 5/27/24 at 3:15 a.m. and his return into the building at 5:39 a.m. *DON D indicated the nursing assessment upon the resident's return into the building had been documented in the facility's internal incident report. 6. Interview on 5/30/24 at 8:20 a.m. with clinical care leader RN/ C revealed she agreed that there had not been any documentation of the functionality of resident 3's wander guard. 7. Interview on 5/30/24 at 9:11 a.m. with DON D regarding a progress note in resident 3's EMR regarding a second elopement revealed: *She was unsure of why a progress note had been made on 5/27/24 at 9:41 p.m. that indicted resident 3 had been outside of the building waving at cars. *She had not been aware of that elopement or another elopement by resident 3. 8. Review of the SD DOH FRI submitted on 5/31/24 at 4:00 p.m. regarding resident 3's second elopement revealed: *State surveyor was in the building and called out a progress note of an elopement. After further investigation the resident was confirmed eloping. *Investigation conclusion revealed: -Cameras was reviewed and confirmed that resident did exit the building after pushing on the outside door for 15 seconds. Staff responded to the alarm and escorted the resident back inside. Resident left the building at 8:06 p.m. and was escorted back into the building at 8:20 p.m. 9. Review of the provider's July 2023 Elopement policy revealed an elopement was defined as When a resident who needs supervision leave the premises or a safe area without authorization.